Download Prudent Healthcare – The Provisional Principles

Prudent Healthcare – The Provisional Principles
1. Introduction
The challenge to drive forward an excellent healthcare system for NHS Wales,
within an era of severe financial restraint, continues to exercise Welsh Government,
health boards and Trusts, not only in Wales, but in other health systems within the
UK and internationally. The situation in Wales is particularly acute because of the
progressive underfunding gap for NHS Wales. It therefore requires immediate and
urgent actions to ensure that the resources we have at our disposal are being used
to best effect, achieving the best outcomes for people at the least cost. This
necessitates a comprehensive understanding of where resources are currently being
invested and the impact and outcomes delivered, alongside a clear rationale for
disinvestment and reinvestment decisions. It also requires a fundamental culture
change to embed this not only across the health and social care systems but also
with members of the public and the media.
2. Prudent Healthcare
The Bevan Commission outlined its approach and thinking to Prudent Healthcare in
its discussion paper entitled ‘Simply Prudent Healthcare – achieving better care and
value for money in Wales’.
Prudent Healthcare is defined as ‘healthcare which is conceived, managed and
delivered in a cautious and wise way characterised by forethought, vigilance
and careful budgeting which achieves tangible benefits and quality outcomes
for patients’
Prudent healthcare is not about rationing. Instead it aims to deliver health care that
fits the needs and circumstances of the patient and actively avoids ineffective care
that is not to the patients’ benefit. It requires healthcare professionals and
government to use resources effectively and efficiently and where a wasteful
allocation of scarce resources is generally regarded as being unacceptable and an
injustice. Common sense principles and practices such as Programme Budgeting
and Marginal Analysis (PBMA) will help to identify interventions and initiatives whose
benefits are not large enough to meet the additional costs incurred. Interventions not
normally used (INNU) http://www.england.nhs.uk/ourwork/d-com/policies/ssp/ , NICE
evidence of ineffective treatments and new service models for improved delivery all
contribute to a Prudent Healthcare approach.
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The objectives for Prudent Healthcare in Wales must ensure that:
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Healthcare fits the need and circumstances of the citizen
Actively avoids harm and waste
Abandons treatment or care that brings little or no benefit and
Maximises the limited financial resources which can be drawn upon
Adopts evidence based medicine at scale and pace
3. The Provisional Principles
The potential benefits which would be brought to NHS Wales by the adoption of a
prudent approach to healthcare, needs to be thoroughly explored and assessed. As
a first step in that direction it is necessary to formulate a set of basic principles which
will underpin prudent healthcare in a Welsh context and are predicated on the
precepts articulated by Aneurin Bevan. However, principles alone will make little
difference if not applied in practice and therefore we should all take responsibility,
including the public, patients and professionals, for their adoption and application to
the nature and manner of care or support received.
The following principles identify the high level levers for change, which need to be
adopted to make sure we all take a responsible attitude to healthcare in Wales.
These are based upon the fundamental needs of the individual, not the system or the
professional. They will require both organisational and professional ownership and
accountability, working in a co-productive way with people to best meet their needs.
For most, providing the Right Care in the Right Place at the Right Time and by the
Right Person will not be new, however, we fail to achieve this. The Bevan
Commission wishes to reinforce this aspiration as an overall aim implicit within
Prudent Healthcare. This builds upon the Six Quality Domains and benefits they could
bring to NHS Wales, identified by the Institute of Medicine and reinforced by 1000 Lives as
follows;
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Stop doing things where there’s evidence they don’t work
Invest only in what gives tangible benefits
Investigate areas where evidence is not clear
Improve quality and clinical outcomes
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Domains
Benefits
Patient Centeredness
Improved engagement, improved personal care and less
litigation and complaints
Patient Safety
Less adverse results
Efficiency
Removing unnecessary processes, streamlining the system
of care
Effectiveness
Undertaking interventions based upon sound evidence
Timeliness
Reducing waiting times and queues, prioritisation based on
need
Equity
Ensure similar outcomes for people with similar needs,
different outcomes for people with different needs
Prudent Healthcare is predicated on the notion that the use of £1 or 1 hour of a person’s
time in one area inevitably means that they are not available for use in other areas. The
benefits that would have been derived from their use in other areas would be lost or
sacrificed. It is therefore essential that the limited time and funds available within healthcare
are channelled into the activities and areas that will maximise the benefits, for patients or the
public as a whole, generated from their use. Determining the activities and areas into which
resources should be allocated can be complex, particularly when balancing individual
benefits against population health gain.
To help in this a ‘common currency’ is needed to enable the relative benefits arising from the
range of activities to be compared. One such measure is that of the quality adjusted life year
(QALY), which combines the additional life years derived from the healthcare intervention
with a measure of the quality of those additional life years. This is the metric employed by
NICE and the All Wales Medicines Strategy Group (AWMSG) in assessing the relative worth
of medicines and other technologies, which allows comparisons to be made between
interventions across all areas of health and social care to assess the extent to which they
can be regarded as representing value for money.
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Principle 1 – Equity based care, treating greatest need first
Definition
Prudent healthcare is that which is infused with a sense of equity. It provides us with
a way of matching need and spending. This means that care will be focused on
those with the most serious health needs first. They will be prioritised for care/
treatment or targeted interventions, irrespective of time or place.
Aims
The intention is to ensure that maximum resources should be allocated to where our
needs are greatest, at both and individual and population level. It should allow us to
go on preserving and promoting the fundamental Bevan principle, that it is your
clinical need and nothing else that matters when it comes to deciding your treatment
by the National Health Service in Wales. This aims to achieve greater equity on the
basis of need, not on time or targets. This also recognises the requirement to provide
the best care needed at the most appropriate facility and time, with a level of
expertise to maximise the best outcomes for the patient.
Actions
To achieve this the NHS will need to develop an appropriate prioritisation process
which recognises clinical need is paramount and where delay can result in serious
deterioration in health status. There will be a pressing need to adjust the system of
waiting times to more accurately represent clinical priorities, ensuring that
diagnostics and assessment facilities are readily available to relevant health
professionals to enable accurate and timely decisions relating to clinical priorities.
Examples
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Fast track in ambulances ensuring that those who are most in need are
prioritised.
Appropriate referrals to specialist care and treatment.
Prioritise those in most need of treatment in primary and community care
Targeting more vulnerable groups for lifestyle interventions etc. Some referral
management systems have interfered with access on clinical need. They can
help weed out referrals that may be more appropriate elsewhere
Principle 2 –Do no harm
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Definition
This means that every clinician will need to be satisfied that due consideration is
given to avoiding measures or interventions which may harm a person physically
and/ or mentally, in the short or in the long term.
Aim
The aim is to ensure that the intervention, on the balance of probability, is likely to
effect a tangible beneficial outcome that will retain optimum health compared with
other possible interventions, based on dialogue and agreement between the clinician
and patient. Where there are no interventions with sound evidence of efficacy
appropriate for the patient and their circumstances, the clinician would provide
support and conservative management relevant to the individual’s case. Whatever
intervention is agreed, it should always be based upon the minimum necessary to
bring about the agreed change.
Actions
The principle of treatment should begin with the basic proven tests and interventions,
calibrating intensity of testing and treatment consistent with the seriousness of the
illness and the patient’s own goals. It is not a question of doing all that we can when
doing so may do more harm than good and raise hopes and expectations along the
way. The volume of interventions or treatments should not be the touchstone by
which we measure our success
Harm can also be done by stripping people of their own abilities, removing their
capacities and their ability and confidence to take care of themselves and of others.
Prudent healthcare provides an ethical underpinning for conversations with patients,
to ensure that we engage with them and avoid putting patients through more
treatment than is necessary to address their condition.
This will also require the need to focus on population health, targeting the promotion
of health and prevention of ill health. The NHS often has to fix problems caused by
harmful lifestyle behaviours and greater effort is needed to support, empower and
motivate people to avoid harming their own health and well being.
The NHS will need to establish minimum standards for safety issues (e.g infection
rates, pressure ulcers, cancelled operations, dispensing errors, prescribing errors)
and establish measures to monitor its performance including patient engagement
and achieving patient reported outcomes.
Examples
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Avoidable unnecessary admissions of elderly patients to hospital causes
serious harm dependency and post discharge syndrome.
Unchallenged poly pharmacy causes adverse events iatrogenic disease and
hospital admissions.
Zero tolerance with regard to pressure ulcers.
An uncomplicated UTI in an elderly person living alone may require admission
which can rapidly lead to confusion, falls and increased rather than decreased
morbidity
Use of hypnotics and anxiolytics both in hospital and in the community leading
to falls and other avoidable harms.
Early supported discharge following a stroke
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Principle 3 - Do the minimum appropriate, to achieve the desired outcomes
Definition
This means that no intervention should be carried out unless it is agreed, between
the clinician and the patient, that the intervention would be better than not adopting
that intervention at all.
Aim
The aim here is to go beyond the ‘do no harm’ approach to one in which an
intervention must do more measurable good from a patient perspective, than not
introducing it. It is about providing an ethical approach to treating patients in which
clinical needs and clinical prioritisation determines how services are provided. It aims
to deliver healthcare that fits the needs and circumstances of patients and actively
avoids ineffective and wasteful care that is not to the patients’ benefit
Actions
Where an intervention is justified, it should always be the minimum and most timely
necessary to achieve, the agreed change or outcome. The benefit of interventions
should take full account of patients' own desired outcomes, and patients should be
helped to think through what outcome they might desire and what is clinically
realistic. For example, preventing or delaying further deterioration would be
preferable to adopting a more invasive treatment, provided the outcomes met the
patients’ needs. The system should also ensure that patients are provided with
enough support to take care of themselves appropriately.
All interventions should be considered in the light of the patient-reported outcome
measures (PROMS) bearing in mind desired outcomes, as above. Such outcomes
should be routinely gathered by Health Boards and form the basis of monitoring the
quality of the care provided. We should help ensure that patients are fully informed of
the options, evidence and likely outcomes as well as being actively engaged in the
decision making process.
Examples
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GP/Consultant dialogue and, in particular, overcoming a delay when it is
clinically indicated that the patient needs justify attendance at the next clinic.
The potential further delay is likely to result in a deterioration in the patient’s
illness before they are assessed or treated
Availability of rapid diagnostics, clinical management advice (GP/Consultants
dialogue) and, for example, physiotherapy for rapid treatment of injury and
proper rehabilitation after major surgery - especially joint surgery
Evidence suggests that bowel screening programmes are identifying ‘polyps’
that would resolve in due course without intervention, but where unnecessary
surgery has now become the norm
Early identification and proactive management of heart failure using natriuretic
peptide tests by GPs
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Principle 4 - Choose the Most Prudent Care, openly together with the patient.
Definition
This means that people should be actively involved in making decisions about the
treatment or care they wish to receive. The emphasis should at all times be on
transparency, with patients and clinicians working in genuine partnership with an
abiding focus on the mutually desired outcome.
Aim
This aims to ensure that people are given sufficient access to reliable information to
help them make decisions, with time for reflection and the chance to explore what
the evidence means for them and their own personal circumstances. They will need
to fully understand the risks and what the alternatives may be, with the benefit of
expert advice. Greater transparency and public engagement will be essential in
ensuring this is done with people not to them. We must ensure openness and
transparency in the clinical decisions we make so that the public can trust and value
professional advice and expertise.
Actions
The most prudent decisions about what healthcare should be given are usually those
made by the patient and their clinicians, working in partnership. Ultimately, patients
are the only people capable of making the right decision about their own healthcare.
However they usually need help to access, understand and apply the available
evidence on outcomes, consequences and alternatives, and then to think through
what would be best for them. The NHS has a responsibility to help in each of these
aspects, in the way the patient wants. It can take time, great inter-personal skills, IT
support, and above all, a willingness and ability to respond to the patient. It also
requires good evidence on what actually are the longer-term outcomes, as
experienced by patients. The NHS too often focuses upon the immediate impact,
rather than upon whether the intervention actually improves the quality of life over
time.
If the NHS gets this right, patients themselves will become the biggest drivers of
prudent healthcare; get it wrong, and patients lose their beneficial influence on the
care provided.
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Examples
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Some surgery has very good outcome data as for example in elective surgery
for aortic aneurysm. Other surgery has less successful outcomes, especially
for the elderly who find appropriate rehabilitation difficult or when availability of
this is limited
Use of alternatives in removal of polyps rather than invasive surgery – e.g
colonoscopy rather than surgery can produce similar outcomes without
mortality risk and at lower cost
Enhanced Recovery After Surgery Programmes (ERAS) where patients are
actively engaged in their post operative rehabilitation, such as knee
replacements
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Principle 5 - Consistently apply evidence based medicine in practice
Definition
This means that where there is no sound evidence for the clinical efficacy and costeffectiveness of an intervention or procedure, then it should not be undertaken.
Aim
Health professionals and organisations will need to ensure that where a treatment or
intervention has been initiated for which there is limited evidence for its continuation;
there will be a need to discuss and agree with the patient how its removal may be
managed. The NHS must be transparent and engage the public in prudent
healthcare. The principles themselves provide sound efficacy for future practice and
greater clarity on what services can be provided and what cannot be provided.
Fertility treatment or the latest expensive anti cancer drug may well fall into this later
category.
Actions
NICE has a catalogue of ‘don’t do it ‘ clinical interventions that do not generate
benefit (Appendix/ link). They include 867 things that NICE say are no longer
clinically worth doing.
Where evidence is questionable there needs to be a cascade or graduation of the
treatment in relation to the strength of evidence and reflecting the consensus of
medical judgement and opinion. Even for those areas where the evidence is strong,
in some individuals there may still be limited benefit or tangible outcomes. In such
circumstances discussion should take place with the patient as to whether this
should be continued and whether there are any other appropriate interventions of
benefit or not.
The use of techniques for determining priorities must become the norm in informing
decisions relating to the provision and delivery of interventions and treatments.
Examples
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Grommets, tonsils , back surgery, knee surgery and shoulder surgery - all
controversial in some instances and without proper physiotherapy and after
surgery care the outcomes are poor
Inappropriate therapeutic management of chronic pain which has seen a
dramatic increase in the prescription of medications for which the evidence of
success in the context of an individual patient is wanting.
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Greater utilisation of ‘stopping rules’ to cease treatments that have no or
minimal effect at individual patient level – examples of expensive medications
being continually prescribed without regular monitoring of impact on patient
Quality and safety agenda has to be given greater priority
Excessive/inappropriate use of CT/MRI scans
Do we need to ask for non urgent tests at night?
Are we using the most cost effective prosthesis for joint replacements?
Are we doing too many unnecessary follow ups in the clinics?
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Principle 6 – Co create health with the public, patients and partners
Definition
This means that where medical and therapeutic solutions are not the best to resolve
the patient’s health problems and needs, then alternative approaches should be
actively sought.
Aim
The aim here is to encourage and motivate the public, patients and other partners
who should all take responsibility to address these in the most appropriate way.
Actions
Individuals should be partners in their own care and should be motivated and
encouraged to share responsibility to address their problems. In a prudent
healthcare world we need to change the way we think about public and population
health. We have to move from education to motivation and from individual to
environmental changes, to turn the good intentions into actions.
Communities should be engaged in co creating healthy communities in which they
live. Other partners such as local government and the third sector should also work
together using their skills, knowledge and networks to enable citizens to live ‘Happy
Healthy Lives’ in the places where they live, work and play. We should all recognise
and address the underlying determinants of health, and use local assets to help co
produce health in the most appropriate way, to achieve the best outcomes for all.
Prudent healthcare is not just about how many tests or interventions we can do. It is
about the more we can do at a citizen level, population level and primary care level
to ensure a better service can be provided.
Prudent healthcare provides the ethical framework for co producing health with
people. Having the right conversations around ‘what can we do together to address
the problems you have?’ Rather than ‘what can I do for you?’ reinforcing people’s
own strength and maximising their own abilities. Too often, the NHS seeks to apply
clinical remedies to problems which are not amenable to such an approach. This
‘medicalisation’ of social and other issues is often the result of a simple lack of
availability of better alternatives; it can also be because people are not assisted to
adapt and cope with problems that can never be entirely removed (supported ‘self
care’).
The NHS needs to work much better with its partners in social care, housing,
education, and others, especially those in the third sector, to make sure that
appropriate alternatives are available and skills and resources are combined to help
people live with those aspects of their lives for which there is no other remedy.
Resources may be relatives, friends, neighbours & friendly & professional societies
which could all be of benefit to a person’s health.
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The NHS will need to ensure it places appropriate emphasis on addressing the
underlying causes of ill health, motivating and supporting people to help themselves
and live healthy lives in partnership with all concerned.
Examples
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Community volunteering – wide range of support given across communities
particularly to those who are most vulnerable and in greatest need
Time banking – encourages people to give their time to support community
interests which can be exchanged for other services and support
WRVS – ‘Red Robin’ Scheme – provides volunteer support to patients in
hospitals and on discharge home
Experience based service co-design – planning and designing services with
the people using them (e.g mental health services)
Education for Patients Programme – structured education programme to help
patients self manage their conditions
Simple measures within the home can both prevent accidents, (e.g, hand rails
on stairs) and assist infirmity and morbidity (e.g, easily accessible bathing
facilities such as a shower rather than a bath)
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